# NTSB ERA12LA394: Piper PA-28-180, N9238J, Ocilla, GA, June 13, 2012

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: June 13, 2012, 10:15 local (14:15 UTC)
- Place: Ocilla, GA
- Coordinates: 31.5725, -83.442497 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=31.5725&lon=-83.4425&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341)
- Highest injury: Minor injuries
- Injuries: 1 minor
- Status: Completed, report May 9, 2013
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 83959
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA394
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83959/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83959
- Page: https://openairdocs.org/ntsb/ERA12LA394

## Probable cause

A failure of the No. 2 cylinder connecting rod due to a lack of lubrication, which resulted in a total loss of engine power.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [Piper PA-28-180, 4 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=7102808), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md)
- [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Piper PA-28-180, 5 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102808), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md)
- [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-180, 6 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7102808), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-180, 37 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102808), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-180, 40 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102808), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Piper PA-28-180, 8 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=7102808), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md)

## Analysis

The pilot was flying the airplane under the conditions specified in a Special Flight Permit to reposition it for a potential sale. The airplane and engine were inspected by a certificated mechanic in accordance with the permit requirements before the flight. During cruise flight, the engine began to “sputter.” The pilot turned to find a landing field, then heard a loud noise, and the engine lost all power. The pilot performed a forced landing in a cotton field; however, the landing gear collapsed in the soft soil and the airframe sustained substantial damage. Subsequent examination of the engine revealed puncture holes in the upper and lower sections of the engine case. The No. 2 cylinder connecting rod was separated from the crankshaft. The recovered parts of the crankshaft showed indications of heat distress and a lack of lubrication. The Nos. 3 and 4 cylinder connecting rods and rod bearings were still connected to the crankshaft; however their failure appeared imminent because of a severe lack of lubrication. All other crankshaft bearings appeared normal. The No. 1 cylinder connecting rod and bearing were normal in appearance with the exception of an overload fracture near the piston end. It is apparent that the No. 2 cylinder connecting rod end failed first due to a lack of lubrication, and the rotating and moving parts fractured the No. 1 cylinder connecting rod end, resulting in complete engine stoppage.

## Factual narrative

On June 13, 2012, about 1015 eastern daylight time, a Piper PA-28-180, N9238J, was substantially damaged following a loss of engine power and forced landing near Ocilla, Georgia. The certificated private pilot sustained minor injuries. The airplane was registered to a corporation and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91, as a ferry flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated at Livingston, Tennessee (8A3), about 0700 and was destined for Clearwater, Florida (CLW). According to the pilot, he was flying the airplane to Florida for a potential sale. While at 2,500 feet mean sea level, the engine began to “sputter.” He turned to the north in search of a landing field. He heard a loud noise and the engine lost all power. He force landed the airplane in a cotton field and the landing gear collapsed in the soft soil. A Special Flight Permit was issued on June 7, 2012 by the Nashville, Tennessee FAA Flight Standards District Office to allow the pilot to fly the airplane to CLW for the potential sale. The permit required that the airplane be inspected by a certificated mechanic or repair station to determine if the airplane was safe for the intended flight. The reason for the permit was to allow the flight to be conducted without a current annual inspection. According to the aircraft logbooks, the last annual inspection was accomplished on March 29, 2007. An inspection was performed on June 7, 2012 to comply with the Special Flight Permit. On the same day, the mechanic changed the engine oil and oil filter and performed an engine run-up with no anomalies noted. A Federal Aviation Administration (FAA) inspector responded to the accident site and examined the wreckage. The inspector confirmed substantial damage to the engine firewall and fuselage. An initial examination of the engine revealed damage to the number one cylinder and there was a hole in the upper case. The engine oil sump contained oil. The wreckage was recovered to Tennessee where a subsequent examination of the engine was performed. On October 1, 2012, the NTSB investigator-in-charge performed an examination of the engine at the owner’s storage facility at Livingston, Tennessee. External examination revealed a puncture hole in the upper right side case and a puncture hole in the lower left side case. The end of one connecting rod protruded through the lower left case and could not be moved by hand. The engine-driven oil pump was removed and examined. When manually rotated, there was no binding or noise and the gears turned smoothly. Suction was observed as the drive coupling was rotated. The unit was disassembled and no anomalies were noted. The unit was free of contaminants and the internal gears were coated with oil. The engine case was opened to facilitate inspection of the internal engine components. The end of the number one connecting rod was fractured and penetrated thelower, left case. The rod remained attached to the crankshaft and exhibited overload signatures. After removal from the crankshaft, the connecting rod bearing was found lubricated with oil and the bearing was normal in appearance. There were no signs of heat distress or lack of lubrication. The attachment point on the crankshaft was also lubricated with oil and free of heat or unusual wear. The number one cylinder and piston were damaged and could not be removed from the case. The number two connecting rod was not connected to the crankshaft. Small parts of the connecting rod and rod cap were found; however, the entire connecting rod was not accounted for. The located parts showed indications of heat distress and lack of lubrication. The number two cylinder and piston were damaged and could not be removed from the case. The crankshaft surface at the number two connecting rod showed significant wear, heat distress, and lack of lubrication. Some extruded bearing material remained attached to the crankshaft in this area. The numbers three and four connecting rods remained attached to the crankshaft. The rods ends at the crankshaft exhibited significant discoloration, surface corrosion, heat distress, and lack of lubrication. The numbers three and four connecting rods were removed from the crankshaft and inspected. The connecting rod bearings were severely scored, worn, and exhibited heat distress and a lack of lubrication. The crankshaft surfaces at the number three and four connecting rod attachment points showed significant wear, heat distress, and lack of lubrication. All crankshaft bearings on the engine case were found lubricated with oil and the bearings were normal in appearance.

## Aircraft

- Registration: [N9238J](https://openairdocs.org/deregistered/N9238J-2018-02-20), registration cancelled 2018-02-20, S/N 28-3312, built 1966 (OpenAirDocs)
- Reported make and model: PIPER PA-28-180
- Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-3312
- Airframe hours: 3582
- Engines: LYCOMING O-360-A3A 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Ferry, Part 91
- Operator: Edward M. Butler II
- Registered owner: Butler Family Lp
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 29, 2007, 23 hours before
- Departed: 8A3, Livingston, TN
- Destination: CLW, Clearwater, FL

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 35; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; flight hours: 340 total, 335 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 350° at 3 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 86 °F, dew point 68 °F
- Altimeter: 29.95 inHg
- Observed at: MGR, 42 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20120613011269A](https://openairdocs.org/incident/20120613011269A), Jun 13, 2012: Piper PA-28-180, Ocilla, GA, Substantial damage. On June 13, 2012 aircraft N9238J left livingston municipal airport (8A3) livingston TN ferrying for maintenance to clearwater air park clearwater FL (kclw).…

## Docket (17 files)

The files NTSB released with the investigation on March 19, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83959. 19.7 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 968 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379130&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Special Flight Permit (item 2, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379131&FileExtension=.PDF&FileName=Special%20Flight%20Permit-Redacted.PDF
- Excerpts - Maintenance Logbooks (item 3, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379171&FileExtension=.PDF&FileName=Excerpts%20-%20Maintenance%20Logbooks-Redacted.PDF
- Photo 1: Main Wreckage, View from Front (FAA Digital Photo) (item 4, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379133&FileExtension=.PDF&FileName=Photo%201%3A%20Main%20Wreckage,%20View%20from%20Front%20(FAA%20Digital%20Photo)-Master.PDF
- Photo 2: Main Wreckage, View from Aft (FAA Digital Photo) (item 5, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379134&FileExtension=.PDF&FileName=Photo%202%3A%20Main%20Wreckage,%20View%20from%20Aft%20(FAA%20Digital%20Photo)-Master.PDF
- Photo 3: Hole in Upper Engine Case (NTSB Digital Photo) (item 6, .PDF, 906 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379137&FileExtension=.PDF&FileName=Photo%203%3A%20Hole%20in%20Upper%20Engine%20Case%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 4: Hole in Lower Engine Case (NTSB Digital Photo) (item 7, .PDF, 884 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379138&FileExtension=.PDF&FileName=Photo%204%3A%20Hole%20in%20Lower%20Engine%20Case%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 5: Left Engine Case and Crankshaft (NTSB Digital Photo) (item 8, .PDF, 966 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379139&FileExtension=.PDF&FileName=Photo%205%3A%20Left%20Engine%20Case%20and%20Crankshaft%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 6: Right Engine Case (NTSB Digital Photo) (item 9, .PDF, 941 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379140&FileExtension=.PDF&FileName=Photo%206%3A%20Right%20Engine%20Case%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 7: Forward Crankshaft, #3 Connecting Rod on Left Side of Photo (NTSB Digital Photo) (item 10, .PDF, 937 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379142&FileExtension=.PDF&FileName=Photo%207%3A%20Forward%20Crankshaft,%20%233%20Connecting%20Rod%20on%20Left%20Side%20of%20Photo%20%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 8: Aft Crankshaft, #3 and #4 Connecting Rods in View (NTSB Digital Photo) (item 11, .PDF, 877 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379150&FileExtension=.PDF&FileName=Photo%208%3A%20Aft%20Crankshaft,%20%233%20and%20%234%20Connecting%20Rods%20in%20View%20%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 9: #1 Connecting Rod, Disassembled (NTSB Digital Photo) (item 12, .PDF, 809 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379144&FileExtension=.PDF&FileName=Photo%209%3A%20%231%20Connecting%20Rod,%20Disassembled%20%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 10: #2 Connecting Rod Parts, Found Inside Crankcase (NTSB Digital Photo) (item 13, .PDF, 763 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379146&FileExtension=.PDF&FileName=Photo%2010%3A%20%232%20Connecting%20Rod%20Parts,%20Found%20Inside%20Crankcase%20%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 11: #2 Cylinder Damage (NTSB Digital Photo) (item 14, .PDF, 866 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379148&FileExtension=.PDF&FileName=Photo%2011%3A%20%232%20Cylinder%20Damage%20%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 12: #3 Connecting Rod, Disassembled (NTSB Digital Photo) (item 15, .PDF, 886 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379151&FileExtension=.PDF&FileName=Photo%2012%3A%20%233%20Connecting%20Rod,%20Disassembled%20%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 13: #4 Connecting Rod, Disassembled (NTSB Digital Photo) (item 16, .PDF, 843 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379152&FileExtension=.PDF&FileName=Photo%2013%3A%20%234%20Connecting%20Rod,%20Disassembled%20%20(NTSB%20Digital%20Photo)-Master.PDF
- Photo 14: Engine Crankshaft, Connecting Rods Removed (NTSB Digital Photo) (item 17, .PDF, 948 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379154&FileExtension=.PDF&FileName=Photo%2014%3A%20Engine%20Crankshaft,%20Connecting%20Rods%20Removed%20%20(NTSB%20Digital%20Photo)-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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